MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 INJURY NUMBER MOTION FOR LEAVE TO WITHDRAW - , Employee vs. , Employer and , Insurer , Third Party Administrator ) ) ) ) ) ) ) ) ) ) ) ) ) ) + Date of Accident/ Occupational Disease: MOTION FOR LEAVE TO WITHDRAW *On behalf of the Employee Employer / Insurer / Third Party Administrator (Please circle the appropriate party.) COMES NOW, the undersigned attorney and requests Leave to Withdraw as attorney for the (specify the name of the party). In support of the Motion, the undersigned states as follows: Are you requesting a hearing to be set on this Motion: Is it set for a The docket date is Are you filing a Lien in this case: Yes Pre-hearing . No Yes No Mediation Respectfully submitted, Signature Attorney Name Law Firm Address Leave Granted: Administrative Law Judge Is this case set on the docket: Hearing. Yes No Phone No. Fax No. Bar No. E-mail Address CERTIFICATE OF SERVICE DIVISION USE ONLY Date: I certify that a copy of this Motion for Leave to Withdraw was mailed or hand delivered to all parties of record, or if represented by an attorney, to their attorneys of record this day of , 20 . Attorney's Signature Attorney's Name (Printed) Address (if different than above) DATE STAMP Bar No. Date *The attorney submitting this withdrawal has notified or attempted to notify his/her client of the intent to withdraw pursuant to Missouri Supreme Court Rule, Rule 4-1.16. + WC-236 WC-236 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com